Exploratory Thoracotomy for Nonresectable Lung Cancer

doi:10.1378/chest.107.4.1058

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Volume 107, Issue 4, April 1995, Pages 1058-1061

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We sought to evaluate the effect of new diagnostic modalities on patients explored surgically for inoperable lung cancer. From July 1983 to February 1992, 335 patients underwent thoracotomy for lung cancer. Thirty-three of the 35 patients with nonresectable disease had sufficient data for analysis and underwent chest radiography (CXR), CT scan, and bronchoscopy. The study was terminated when video-assisted thoracoscopy (VAT) was introduced at the institution. Causes of nonresectability included significant N2 disease not diagnosed preoperatively (n=11), tumor invasion of contiguous mediastinal structures (n=8), and insufficient pulmonary function (n=4). Four patients were left with unresected disease because of thoracic metastasis. Two patients had technically unresectable disease; three patients were explored surgically because diagnoses could be obtained by no other means. One patient was found to have small cell cancer. Data analysis demonstrated that 19 of 33 thoracotomies could potentially have been avoided or resulted in resection with current techniques. Refinement of imaging criteria, a judicious surgical approach to N2 disease, and VAT may significantly reduce thoracotomies for nonresectable lung cancer.

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MATERIAL AND METHODS

All patients undergoing exploratory thoracotomies for lung cancer between July 1983 and February 1992 were identified in the thoracic surgery operative records. The charts of those patients surgically explored without resection were examined for demographics, symptoms, and preoperative assessment (hematocrit, liver function studies, spirometric testing, chest radiograph [CXR], CT, bronchoscopy, cervical mediastinal exploration [CME], and anterior mediastinal exploration [AME]). Operative

RESULTS

During the study period, 335 patients underwent thoracotomy for primary lung cancer, of whom 300 (89.6%) proved to have resectable disease. Of the 35 patients with unresectable disease, 33 charts had sufficient data available for review and formed the database for our review.

The study comprised 28 men and 5 women ranging in ages from 45 to 72 years with a mean age of 58.5 years.

The most common symptoms were cough, hemoptysis, and pain. Five were asymptomatic, and 14 patients had multiple

DISCUSSION

Exploratory thoracotomy for nonresectable cancer is a morbid procedure that yields no benefit to the patient in terms of longevity or palliation.2, 4, 5 The goal of thoracic surgeons should be to eliminate such procedures. It was hoped that improved imaging modalities such as CT and magnetic resonance imaging would contribute to this goal.³ The additional use of video-assisted thoracoscopy (VAT) and a more aggressive approach to positive mediastinal adenopathy found at surgery6, 7 should

References (9)

FergusonM et al.
Regional accuracy of computed tomography of the mediastinum in staging of lung cancer
J Thorac Cardiovasc Surg
(1986)
RattoGB et al.
Improving clinical efficacy of computed tomographic scan in the preoperative assessment of patients with non-small cell lung cancer
J Thorac Cardiovasc Surg
(1990)
ThermannM et al.
Efficacy and benefit of mediastinal computed tomography as a selection method for mediastinoscopy
Ann Thorac Surg
(1989)
UnruhH et al.
Mediastinal assessment for staging and treatment of carcinoma of the lung
Ann Thorac Surg
(1986)

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Cited by (15)

Routine surgical videothoracoscopy as the first step of the planned resection for lung cancer
2009, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Other authors, in a series of 650 patients with clinically staged resectable NSCLC, observed 7% of inoperable disease at thoracoscopy, mainly owing to pleural metastasis or direct invasion of vital structures.25 The rate of exploratory thoracotomies after conventional staging in the literature ranges from 3% to 25%.2-7 In a previous analysis of our experience of more than 2000 pulmonary resections carried out between 1967 and 1980, the rate of exploratory thoracotomy had been 19% but had decreased to 11.6% in the 1980s (1980–1991), after the progressive introduction of CT scanning in preoperative evaluation.8
Notwithstanding preoperative staging, a number of procedures still end in an exploratory thoracotomy as a result of unexpected findings. The aim of this work is to evaluate the validity of routine videothoracoscopy, performed as the first step of every planned resection for non–small cell lung cancer, to assess tumor resectability and feasibility of the resection through thoracoscopy.
From November 1991 to December 2007, in our department, 1306 patients with non–small cell lung cancer, judged operable at conventional staging, underwent videothoracoscopy before the operation. Thoracoscopy revealed inoperability in 58 (4.4%) patients, mostly owing to pleural dissemination (2.5%) or mediastinal infiltration (1.7%). In the remaining 1248 (95.6%), thoracoscopy did not reveal inoperability. Of these, 449 (34.4%) underwent thoracoscopic resection. The other 799 (61.2%) underwent thoracotomy: 767 underwent resection, but 32 (2.5%) had an exploratory thoracotomy. Thoracoscopy had suggested unresectability in 7 (0.5%) patients, had been incompletely carried out in 4 (0.3%), and was unfeasible in 21 (1.6%) owing to insurmountable technical reasons. In our previous series from 1980 to 1991 the exploratory thoracotomy rate had been 11.6%. In the present series, after the introduction of routine thoracoscopy in the staging process, the exploratory thoracotomy rate was 2.5%. Thoracoscopy was reliable in excluding unresectability (negative predictive value 0.97). The global percentage of correct staging was significantly better (P < .0001) by thoracoscopy (73.3%) than by computed tomography (48.7%). Considering T descriptor, video-assisted thoracic surgery correctly matched with final pathologic staging in 96.2% of patients.
Routine preliminary videothoracoscopy ensured assessment of tumor resectability and feasibility of the resection through thoracoscopy and limited unnecessary thoracotomies.
What to do with "surprise" N2? Intraoperative management of patients with non-small cell lung cancer
2008, Journal of Thoracic Oncology
Citation Excerpt :
There seems to be little difference in the perioperative mortality of an exploratory thoracotomy versus a resection. The average reported operative mortality after an exploratory thoracotomy is 4% (0–7%).1–7 The average operative mortality for pulmonary resection is approximately 4%,1 although more recent series suggest it has decreased to about 2%.8–10
There is debate about how patients should be managed when malignant involvement of mediastinal lymph nodes is encountered at the time of lung resection. A comprehensive review of the literature demonstrates that differences in which outcomes are reported and how extensively patients were staged preoperatively explain much of the conflicting data. Certain negative and positive prognostic factors can be defined, but in general the outcomes justify proceeding with resection unless it is clear that disease will be left behind. Reasonable arguments can be made that the approach should include a mediastinal lymph node dissection and adjuvant therapy.
Impact of a rescue program on the operability of patients with bronchogenic carcinoma and chronic obstructive pulmonary disease
2007, Archivos de Bronconeumologia
La asociación entre carcinoma broncogénico y enfermedad pulmonar obstructiva crónica (EPOC) se sitúa en torno al 70% en nuestro medio. Aproximadamente un 60% de los pacientes con dichos diagnósticos son rechazados para cirugía de resección del carcinoma broncogénico debido a la intensa alteración de su función pulmonar. El objetivo del presente trabajo es evaluar el efecto de un programa de rescate en la mejoría de la función pulmonar de pacientes con EPOC y previamente descartados para cirugía por la alteración de su función pulmonar.
Se incluyó en el estudio a pacientes con EPOC descartados inicialmente porque se había calculado que su volumen espiratorio forzado en el primer segundo (FEV₁) tras la intervención quirúrgica sería menor de 1 l. Todos ellos participaron en un programa de rescate de 2 semanas de duración que incluía: optimización del tratamiento farmacológico (broncodilatadores inhalados y/o corticoides) y fisioterapia respiratoria intensiva. Se analizó la función pulmonar antes y después del programa.
Se evaluó a 30 pacientes (26 varones y 4 mujeres) con una edad media ± desviación estándar de 66,7 ± 8,15 años y FEV₁ inicial de 1,497 ± 0,27 ml (FEV₁%: 55,7 ± 20,14 l), que no presentaban insuficiencia respiratoria (presión arterial de oxígeno: 77,0 ± 9,4 mmHg; presión arterial de anhídrido carbónico: 41,6 ± 2,4 mmHg). Tras el programa 24 pacientes (80%) pudieron ser aceptados para la resección propuesta al objetivarse una mejoría significativa en la función pulmonar (p < 0,001). Se realizaron 2 resecciones en cuña, 18 lobectomías, 2 neumonectomías y 2 toracotomías exploradoras (por criterios oncológicos). De los 24 pacientes a los que se intervino, en 19 no hubo complicaciones, 2 presentaron fugas aéreas mantenidas, hubo un caso de empiema pleural y otro de hemotórax. Un paciente falleció por sepsis.
El diseño de un programa intensivo farmacológico y de fisioterapia respiratoria permite rescatar para cirugía a un número alto (80%) de los pacientes con EPOC a los que inicialmente se descarta por una alteración importante de la función pulmonar.
Bronchogenic carcinoma and chronic obstructive pulmonary disease (COPD) are strongly associated in our setting, occurring together in around 70% of cases. Approximately 60% of COPD patients who require resection for bronchogenic carcinoma are considered unfit for surgery because of seriously impaired lung function. The purpose of this study was to evaluate the extent to which a rescue program could improve lung function in COPD patients who had previously been considered unfit for surgery because of poor lung function.
The study enrolled COPD patients who had not been considered for surgical resection because they had a predicted postoperative forced expiratory volume in 1 second (FEV₁) of less than 1 L. All of the patients participated in a 2-week rescue program that involved optimization of drug treatment (inhaled bronchodilators and/or corticosteroids) and intensive respiratory physiotherapy. Lung function was analyzed before and after the program.
We evaluated 30 patients (26 men and 4 women) with a mean (SD) age of 66.7 (8.15) years and an initial FEV₁ of 1.497 (0.27) mL (FEV₁% of 55.7% [20.14%]). None of the patients had respiratory failure (PaO₂ of 77.0 [9.4] mm Hg and PaCO₂ of 41.6 [2.4] mm Hg). Twenty-four patients (80%) showed significant improvement in lung function (P<.001) after the program and were admitted for resection. Two wedge resections, 18 lobectomies, 2 pneumonectomies, and 2 exploratory thoracotomies were performed (based on oncologic indications). Nineteen of the 24 patients who underwent surgery had no complications. Two patients had prolonged air leaks, 1 empyema, and 1 hemothorax. One patient died from sepsis.
A large number (80%) of COPD patients previously considered unfit for surgical resection because of seriously impaired lung function can be admitted for surgery following an intensive drug and respiratory physiotherapy rescue program.
Pre-operative plasma erythropoietin concentration and survival following surgery for non-small cell lung cancer
2006, Lung Cancer
Suppression of the effect of the hormone erythropoietin (EPO) on the bone marrow, and an inadequate EPO response to anaemia have been shown to be factors in the genesis of cancer related anaemia. Low haemoglobin (Hb) concentration pre-operatively has been shown to have prognostic significance in patients with surgically resected NSCLC. This study investigates the relationship between pre-operative EPO and survival in patients having surgery for NSCLC.
Pre-operative plasma EPO concentration and haemoglobin concentration were analysed in patients undergoing surgery for NSCLC between April 1998 and January 1999. Full follow-up was available for all patients.
Forty two patients were included. Median EPO concentration was 9.4 mIU/ml, range (3.7–56.4) with 17 patients (40.4%) having values above the normal range. Median haemoglobin concentration was 13.3 g/dl (range 8.5–16.8) with 15 patients (26%) anaemic pre-operatively. Pathological staging revealed 17 (40.4%) patients with stage I, 6 (14.3%) with stage II, 19 (45.3%) with stage III disease. Ten patients had irresectable disease. There was a significant difference in median EPO but not haemoglobin concentration, between the different pathological stages. Survival was significantly lower in patients with pre-operative EPO >10.5 mIU.
Raised pre-operative EPO is associated with reduced survival in patients having surgery for NSCLC. Its measurement should be considered in the pre-operative assessment of patients undergoing surgery for NSCLC. Further research is required to further investigate the biological relationship between EPO and NSCLC.
Optimal management when unsuspected N2 nodal disease is identified during thoracotomy for lung cancer: Cost-effectiveness analysis
2003, Journal of Thoracic and Cardiovascular Surgery
Whether to proceed with lung resection when N2 nodal disease is identified at the time of thoracotomy for lung cancer is controversial. A decision analysis model was developed to address this question.
A meta-analysis was performed on data from reports published between 1990 and 2002 evaluating survival for (1) patients who were treated by initial resection for clinically unsuspected N2 nodal disease (initial resection) and (2) survival for patients undergoing resection after neoadjuvant therapy for N2 nodal disease (no initial resection). Hospital cost data for surgery were derived from our institution, and cost data for chemotherapy and radiation therapy were obtained from current literature. A decision model was developed to compare initial resection to no initial resection from the perspective of the medical center using survival, quality-adjusted life years survival, and cost-effectiveness as outcomes.
The no initial resection option provided better median survival (2.1 versus 1.7 years), quality-adjusted life years (1.8 versus 1.3), and cost-effectiveness, with an incremental cost-effectiveness ratio of $17,119/quality-adjusted life year. Outcomes were influenced by survival estimates for each treatment option.
When N2 nodal disease is discovered during thoracotomy, the approach of delaying resection until after neoadjuvant therapy provides the best survival and is more cost-effective. This is likely due to the beneficial effects of neoadjuvant therapy and the exclusion of patients with more aggressive disease from the surgical candidate pool.
Systematic nodal dissection in the intrathoracic staging of patients with non-small cell lung cancer
1999, Journal of Thoracic and Cardiovascular Surgery
Objective: Although systematic nodal dissection is accepted as an important component of the intrathoracic staging of disease in patients undergoing thoracotomy for lung cancer, many surgeons still do not routinely perform it. We reviewed our practice to assess the information provided by its routine application even when lymph node metastases are considered unlikely. Methods: The records of 240 patients undergoing thoracotomy for clinically staged cT1-3 N0-1 non–small cell lung cancer were reviewed. In 5 cases (2%) mediastinal dissection was not performed because of specific contraindications and in 8 cases (3%) exploratory thoracotomy was performed. The pathologic findings in the 227 patients who underwent pulmonary resection with systematic nodal dissection were analyzed. Results: The median number of nodal stations, including N1 and N2, examined and submitted separately for histologic assessment was 7 per patient (range 3-13). N2 disease was disclosed in 46 patients overall (20%), including 41 of the 227 patients undergoing pulmonary resection (18%) and 5 of those undergoing exploratory thoracotomy (62.5%). No subgroup had a 0% incidence of N2 metastases. Multivariate analysis showed that younger age, increasing tumor size, left lower lobe origin, and bronchial origin were significant independent variables for prediction of lymph node metastases at the N1 level, the N2 level, or both. Conclusions: Because no clinical or pathologic subset of patients with a negligible incidence of N2 disease could be discriminated, systematic nodal dissection must be routinely employed for accurate intrathoracic staging of non–small cell lung cancer. (J Thorac Cardiovasc Surg 1999;117:246-51)

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The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the US Government.

revision accepted July 26.

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Clinical Investigations: MiscellaneousExploratory Thoracotomy for Nonresectable Lung Cancer

Section snippets

MATERIAL AND METHODS

RESULTS

DISCUSSION

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Clinical Investigations: Miscellaneous
Exploratory Thoracotomy for Nonresectable Lung Cancer